[What is new in 2012 for the specialist in hospital internal medicine?]. / L'année 2012 de la perspective de l'interniste hospitalier.

The knowledge in internal medicine is constantly and so rapidly evolving that practices have to be updated and adjusted to recent scientific rules, in order to improve quality and efficiency in the day to day activities. Residents in the Service of internal medicine of the Lausanne University present several relevant papers published in 2012, whose results are susceptible to change the daily hospital practices. From modest impacts to real revolution, a variety of subjects are discussed in the perspective of evidence based medicine.

[Axillary lymphadenectomy prepared by fat aspiration versus functional axillary lymphadenectomy: preliminary results of a randomized prospective study]. / Lymphadénectomie axillaire préparée par lipoaspiration contre curage axillaire fonctionnel: résultats préliminaires d'un essai prospectif randomisé.

The objective of this study is to compare morbidity between 2 surgical procedures of axillary clearance: functional lymphadenectomy by classical dissection versus axillary dissection prepared by liposuction (Suzanne's procedure). Two hundred consecutive patients treated for breast cancer were included in a prospective randomized trial between 1st January, 1995 and 31st January, 1996 (Huriet's law). The assessment (number of nodes, postoperative stay, drainage duration, rate of seromas, number of complications, evaluation of mobility and sensitive disorders) was done on the first, fifth, tenth and thirty postoperative days. There is no significant difference between the 2 groups. The rate of seromas decreased significantly only for fat patients (8/25 versus 21/34, p < 0.05) and for the patients treated with radical mastectomy (17/37 versus 28/39, p < 0.05). In this preliminary study, liposuction does not change postoperative effects of axillary clearance, except for fat patients or after total mastectomy. The liposuction seems to facilitate a better anatomical dissection and a better preservation of the nervous and vascular elements.

[Conservative surgical treatment of retro-areolar breast tumors. Local control and esthetic results]. / Le traitement chirurgical conservateur des tumeurs rétro-aréolaires due sein. Contrôle local et résultats esthétiques.

OBJECTIVE: A retrospective study of local faiture and cosmetic results after conservative surgery for retroareolar breast cancer. PATIENTS AND RESULTS: Seventy-seven patients underwent a conservative surgical procedure between 1983 and 1994. Median follow-up was 37,5 months. Fourteen patients experienced a recurrence (5 local, 2 local and distant, 7 distant). Only two probably interrelated factors were associated with a risk of local recurrence: nipple-areola complex removed or not, and pathological margins. Cosmetic results were evaluated with patient's questionnaires: 40/47 patients (85%) stated they were satisfied. CONCLUSION: In spite of the short follow-up, conservative surgery is a safe procedure for local control only in cases with negative margins. Procedure for nipple areola complex is now questionable. Cosmetic results are achieved if indication of central lumpectomy are confined to small and limited tumors. For other tumors, plastic remodelling is necessary.

[Treatment of intraductal carcinomas. 91 cases treated at Oscar-Lambret Center]. / Traitement des carcinomes intra-galactophoriques. A propos de 91 cas traités au Centre Oscar-Lambret.

During a period of 10 years, 91 ductal carcinomas in situ (DCIS) were operated. After a study of clinical and therapeutics characteristics, the evolution of the DCIS was studied. Eleven recurrences were seen in a period of 41 months. The actuarial risk of recurrence was 11% at 5 years and 17% at 8 years. About half of the recurrences were invasive and occurred 10 times out of 11 in the initial area or nearby. Among several factors studied, the association of radiotherapy with conservative surgery was the only one which reduced significantly the risk of recurrences.

[Preoperative localization of asymptomatic breast lesions by the technique of stereotaxic tattooing and use of a wire. Apropos of 670 cases]. / Repérage pré-opératoire des lésions mammaires infracliniques par la technique du tatouage stéréotaxique et du "harpon". A propos de 670 observations.

OBJECTIVE: To compare the quality of pre-operative analysis of sub-clinical lesions of the breast using a wire and stereotaxic tattooing. METHODS: Between 1983 en 1990, 670 cases were analysed. At first needle or wire localisation techniques were used and then from 1988 onwards stereotaxic tattooing, first with the wire technique combined with it and later by itself from 1989 onwards. PLACE STUDY CARRIED OUT: Oscar-lambret Centre in the Department of Surgery and Radiodiagnosis I, BP 307, Lille Cedex. RESULTS: 190 carcinomas were diagnosed (30.7%) of which 20 were micro-invasive and 46 carcinoma in situ. The efficiency of the analysis was evaluated according to the number of explorations that were necessary to remove healthy tissue around the lesion. The wire technique results were significantly different (15.43% = 339 cases), tattooing with wire (9.13% = 144 cases), and tattooing by itself (6.30% = 135 cases). CONCLUSION: It seems that pre-operative assessment using stereotaxic tattooing is the most reliable of methods because it allows limited excision of the lesion and a more aesthetic approach.

Monoclonal antibodies to Coxiella burnetii for antigenic detection in cell cultures and in paraffin-embedded tissues.

The authors developed monoclonal antibodies to Coxiella burnetti, the agent of Q fever. The selected monoclonal antibody, Cox1D8, did not cross-react with other bacteria and was used for early detection of C burnetti in shell vial cell cultures and for staining C burnetii in paraffin embedded tissues. Formalin or Bouin fixation did not alter the reactivity of the antigen with the antibody. This monoclonal antibody could be useful in the pathologic diagnosis of Q fever hepatitis and endocarditis.

[Preoperative marking of non-palpable breast lesions by the stereotaxic tattooing and "harpoon" technique. 670 cases]. / Repérage pré-opératoire des lésions mammaires infracliniques par la technique du tatouage stéréotaxique et du "harpon". A propos de 670 observations.

OBJECTIVE: To compare the quality of pre-operative analysis of sub-clinical lesions of the breast using a wire and stereotaxic tattooing. METHODS: Between 1983 en 1990, 670 cases were analysed. At first needle or wire localisation techniques were used and then from 1988 onwards stereotaxic tattooing, first with the wire technique combined with it and later by itself from 1989 onwards. Place study carried out: Oscar-lambret Centre in the Department of Surgery and Radiodiagnosis 1, BP 307, Lille Cedex. RESULTS: 190 carcinomas were diagnosed (30.7%) of which 20 were micro-invasive and 46 carcinoma in situ. The efficiency of the analysis was evaluated according to the number of explorations that were necessary to remove healthy tissue around the lesion. The wire technique results were significantly different (15.43% = 339 cases), tattooing with wire (9.13% = 144 cases), and tattooing by itself (6.30% = 135 cases). CONCLUSION: It seems that pre-operative assessment using stereotaxic tattooing is the most reliable of methods because it allows limited excision of the lesion and a more aesthetic approach.

Studies of monoclonal antibody BL2-10D1 as a marker for the detection of the urothelial origin of tumors.

BACKGROUND: In previous studies, the authors demonstrated the value of the monoclonal antibody (MoAb) BL2-10D1 in identifying malignant transitional cells. In this study, the authors evaluate the possible diagnostic value of a murine MoAb, BL2-10D1, raised against human bladder cancer in the determination of the urothelial origin of metastases in a series of 29 patients with metastatic bladder or prostatic carcinoma. METHODS: Using an immunoperoxidase method, BL2-10D1 and anti-prostate-specific antigen (anti-PSA) reactivity were studied, using histologic sections from 18 pelvic lymph nodes and 4 other anatomic sites invaded by transitional cell cancer, and from 7 pelvic lymph nodes containing prostatic cancer. RESULTS: All lymph nodes containing metastases of transitional cell carcinoma were positive with BL2-10D1, whereas all metastases of prostatic cancer were negative; the four instances of distant urothelial metastases were positive with BL2-10D1 MoAb. Conversely, anti-PSA reacted only with prostatic metastases. CONCLUSION: Thus, MoAb BL2-10D1 and anti-PSA complement each other in the separation of cancers of prostatic and urothelial origin, and the BL2-10D1 MoAb has potential usefulness in differentiating between urothelial carcinoma and prostate adenocarcinoma. In patients with bladder tumors of uncertain origin, BL2-10D1 may be helpful in confirming that a tumor is a transitional cell carcinoma.

Neural cell adhesion molecule and prognosis of surgically resected lung cancer.

The prognostic significance of the expression of neural cell adhesion molecule (NCAM), a neuroendocrine antigen in lung cancer, was analyzed by an indirect immunoperoxidase method in 97 surgically treated patients. Reactivity of MOC-1 and S-L 11.14, both cluster-1 monoclonal antibodies directed against NCAM, was positive in all nine small-cell lung cancers and in 16 of 88 (18%) non-small-cell lung cancers. For the latter group, this expression demonstrated a phenotypic heterogeneity that was mainly observed in poorly differentiated squamous cell carcinomas and in stage N2 non-small-cell lung cancers. Patients with NCAM-positive non-small-cell lung cancer proved to have a shorter survival than those with NCAM-negative disease. In Cox's model for multivariate analysis, nodal status and histology were the main independent determinants of prognosis. We therefore concluded that NCAM expression in non-small-cell lung cancer is correlated to nodal status and that it indicates a poor prognosis. These findings confirm that the diversification of lung cancer phenotype leads to tumor progression and brings a negative prognosis to surgically resected non-small-cell lung cancer. However, nodal status remains the most important prognostic variable, suggesting that NCAM expression is only one of numerous biological events that promote tumor progression.

Antibodies to bladder-tumor-associated antigens as prognosis probes in the flow-cytometric analysis.

Monoclonal antibodies directed against bladder tumor cells (10D1, 7C12, 6D1, 3C6, G4 and E7) and human leukocyte antigen (HLe1) were tested by flow cytometry on 68 bladder tumors involving 10 grade I, 29 grade II and 29 grade III tumors (WHO classification). According to their evolution stage, these tumors can be subdivided into 17 stage Pa, 34 stage P1, 7 stage P2 and 10 stage P3. Fifteen normal bladder samples were used as a control. Analysis of DNA content revealed a first group of 31 tumors with a unimodal DNA profile. In the second groups of 37 tumors, the DNA profile was bimodal. Cells from grade I tumors were labelled with 10D1 and 6D1 antibodies; all these cells showed a unimodal DNA profile. Grade III tumor cells were labelled with antibodies G4 and E7; most of these cells showed a bimodal DNA profile. The percentage of HLe1-positive cells decreased with the pathological grade and stage of tumor. The composition of infiltrating leukocytes was different in unimodal and bimodal tumors. In conclusion, cells of low-grade tumors can be identified with 10D1 and 6D1 antibodies, and antigens recognized by G4 and E7 antibodies are mostly expressed by aneuploid cells. HLe1 antibody demonstrates the importance of the inflammatory reaction in bladder tumors. Moreover, in flow cytometry, leukocytes within a tumor could be used as internal reference for precise measurement of the DNA content of tumor cells.

Intrapleural recombinant IL-2 in passive immunotherapy for malignant pleural effusion.

The purpose of this phase 1 study was to determine the toxicity and effectiveness of recombinant interleukin-2 (RU 49637 Roussel Uclaf-France) administered by continuous pleural infusion for 5 days to patients with different histologic subtypes of pleural cancer. Incremental doses of rIL-2 from 3 x 10(6) to 24 x 10(6) were given via a thin catheter inserted into the homolateral pleural cavity. Patients were evaluated before treatment and 36 days after treatment by computed tomography scan and thoracoscopy with biopsy. Twenty-two patients with malignant pleural effusion (15 malignant pleural mesotheliomas, 6 adenocarcinomas, 1 squamous cell carcinoma) were treated. The maximum tolerated dose (MTD) of rIL-2, defined as the dose that produced grade 3 or greater toxic reactions in 50 percent of the patients, was 24 x 10(6) IU/m2/d. Although some side effects were encountered at any dose, tolerance was acceptable. The main side effect was fluid retention (8 of 22) which never exceeded 10 percent of body weight. Responses were achieved in 10 out of 22 patients with 1 complete remission (mesothelioma) and 9 partial remissions (3 adenocarcinomas and 6 malignant pleural mesotheliomas). Based on these results, we recommend that phase 2 studies using rIL-2 at a dose of 21 x 10(6) IU/m2/d via the intrapleural route be undertaken.

[Mass screening for breast cancer in Herault county. First results in women between 40 and 70 years old]. / Dépistage de masse du cancer du sein dans l'Hérault. Premiers résultats chez la femme entre 40 et 70 ans.

A large scale mammography breast cancer screening has begun in Herault county on the first of july 1990. The aim of the project was to determine the impact of two-view mammography upon the size of the tumor and later upon mortality from breast cancer. The women aged 40-70 at entry were invited by mail to the first round of mobile breast screening. Between the start and the 8th of march 1991, 5098 (64%) attended the first round. The cancer detection rate was 5.9/1000, the positive detection rate was 7.75%, the benign malignant surgical biopsy ratio was 1:0.7 and the percentage of surgical biopsies positives for malignancy was 42.6%. Two months after this study, the screening specificity was 96.7% and the sensibility was 92.7%. The rate of tumor size less or equal to 1 cm was 72% (for 30 malignancies) and the rate of mastectomies was 43.3%. These friendly results were compared to those of others breast cancers screenings.

[Stromal luteoma of the ovary. Differential diagnosis of steroid cell tumors]. / Le lutéome du stroma ovarien. Diagnostic différentiel des tumeurs à cellules stéroïdes.

An observation of a stromal luteoma of the ovary is reported. It is a rare tumor (only about thirty cases of it have been published yet), occurring mostly in post menopausal women. Endocrine symptoms and sometimes virilizing signs may be observed. Abnormal vaginal bleeding is the most frequent clinical manifestation. This macroscopically observed tumor is surrounded by ovarian stroma and entirely composed of luteinized cells devoid of crystals of Reinke. Hyperthecosis of ovarian stroma is often observed. Its evolution is always benign. The authors recalled the place of stromal luteoma of the ovary among steroid (lipid) cell tumors and the elements of a differential diagnosis. These tumor might derive from ovarian stromal cells.

Rapid isolation of human endothelial cells from whole blood using S-Endo1 monoclonal antibody coupled to immuno-magnetic beads: demonstration of endothelial injury after angioplasty.

The presence in whole blood of circulating endothelial cells (EC) has been a subject of debate for many years. It could represent a good marker of vessel injury. We demonstrate here that human endothelial cells can be directly isolated and identified in circulating blood by means of an endothelial cell specific monoclonal antibody, S-Endo1, coupled to micromagnetic beads. The specificity and efficacy of the assay were established using normal blood samples with cultured EC added. Specific rosettes formed between EC and beads could subsequently be isolated with a magnet. The rosetted cells were recovered with a yield greater than 80%. Their endothelial origin was confirmed by the positive labelling of von Willebrand factor and thrombomodulin, as well as the presence of Weibel-Palade bodies. We applied this method to demonstrate significantly increased levels of EC in venous and arterial human blood samples in patients undergoing heart catheterization. This new whole blood immuno-separation method may be useful in determining endothelial cell injury in vascular disorders.